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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804150
Report Date: 06/10/2024
Date Signed: 06/10/2024 02:45:50 PM


Document Has Been Signed on 06/10/2024 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WINDSONG OF SONOMAFACILITY NUMBER:
496804150
ADMINISTRATOR:JOHN BELTZFACILITY TYPE:
740
ADDRESS:815 WOOD SORREL DRIVETELEPHONE:
(707) 776-2885
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:95CENSUS: 79DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:John Beltz, Administrator TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Inspection and was welcomed by Business Office Mgr. Elizabeth Alfaro, and met with Administrator, John Beltz. Facility currently has 41 Assisted Living residents and 38 dementia residents in memory care. There are 10 residents currently on Hospice.

Facility tour/inspection began at 8:30 AM:
LPA toured the facility on 6/10/2024 at approximately 8:35 AM with Business Office Manager (BOM) Lizabeth Alfaro and was joined by Administrator John Beltz shortly after; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has a special care plan of operation and programming for residents with dementia. Fire Extinguisher was found to be last charged on 10/16/2023. Facility smoke detectors with combination carbon monoxide detectors are hard wired and sound directly to the fire station. Smoke/carbon monoxide detectors and fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 4/15/2024. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 113.7 degrees F and 128.3 degrees F falling out of Title 22 acceptable regulation of 105 F to 120 degrees F in 5 of 11 resident’s bathroom faucets, all 5 in memory care, boiler was turned down at visit (see LIC809-D).

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Menus are available and provided during meals.

LPA observed that provisions are made for individuals with special dietary needs; facility keeps a variety of items on the menu, and facility has a board in the kitchen with a picture of the resident & a list of dietary needs. Food is available for residents any time of the day. Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2024 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review & interview with Administrator, the licensee did not comply with the section cited above in 3 out of 3 direct care providers did not obatain required annual trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Administrator to submit proof of training to CCL for S1, S2, and S3 by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/28/2024.
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Administrators observation while touring memory care, the facility did not comply with the section cited above by finding residents unlocked lidocane strips in unlocked bathroom cabinet (see pics), shampoos & conditioners with creams of multiple residents in unlocked bathroom cabinets (see pics), & finding cleaning supplies in memory care kitchenett's in unlocked cubbords (see pics) although all removed or lockes placed on cabinets by end of visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(2). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 6/28/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150
VISIT DATE: 06/10/2024
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There is a daily activity schedule for residents posted. Toxins are stored in a locked housekeeping room; although while touring facility at 9:24am LPA, BOM, and Administrator observed cleaning supplies under both sinks of memory care kitchenettes in cabinets without locks (see LIC809-D) Building Service Director Russell Echeverria informed due to upgrades throughout the facility, locks in this area had not been completed yet. Locks were installed by end of visit. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with towels and hand soap dispensers when a private room; although at 8:40am LPA & BOM observed in a memory care bathroom an unlocked cabinet with Lidocaine patches, razors, and other cleaning supplies, see pic (see LIC809-D). Items were removed during inspection and locked in resident bathroom cabinets.

Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. The facility has obtained new flooring throughout and paint, Garden Neighborhood dining area has completed construction due to water leak a year ago.

File Review began at 11:15 AM:
A sample review of five residents & five staff records as well as four resident’s medications was conducted. LPA learned that 5 out of 5 residents have an updated reappraisal/needs & care plan as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. 3 out of 3 direct care staff have not completed annual required trainings (see LIC809-D); 1 out of 3 staff (S1) reviewed did not obtain required proof of 1st Aid certification (see LIC 809-D).

Medication Audit began at 10:45 AM:


Medications were centrally stored in locked medication carts and in the facility medication room at the facility. LPA observed medications of 4 out of 4 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 4 out of 4 residents were found to have all medications entered for residents. Facility uses bubble pack and pharmacy CSMR for all residents at the facility.

Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/10/2024 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with Administrator, the licensee did not comply with the section cited above in 1 out of 3 (S1) direct care providers did not have current 1st Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 6/28/2024.
Type B
Section Cited
CCR
87303(e)(2)

87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 11 residents bathroom faucets measured between 121.8 & 128.3 degrees F (all memory care residents) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Facility to submit proof of log sheet for water temperature measurement for the next 14 days to be submitted to CCL by 6/28/2024. Civil penalties for $250.are being assessed for a repeat violation of the same regulation in less then 12 months.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WINDSONG OF SONOMA
FACILITY NUMBER: 496804150
VISIT DATE: 06/10/2024
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LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have been conducted monthly and in different shifts with the last one being conducted on 5/31/2024. In addition, John Beltz, Administrator Certificate # 7017264740 expires 9/30/2024.

Civil penalties are being assessed for $250. For repeat of same regulation within a 12 month period.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Administrator to update the following documents and to submit to CCL by 6/20/2024:

LIC 308 Designated
LIC 500 Personnel Summary (already received)
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility Resident’s (already received)
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance (already received)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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